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General NPI Number Information
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NPI Number | 1508241936
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Entity Type | Organization
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Legal Business Name | SRCONQUEST
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Dates
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Enumeration Date | 07/27/2015
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Last Update Date | 07/27/2015
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Provider Practice Location Address
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Address Line | 3255 NW 94TH AVE #8736
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City | CORAL SPRINGS
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State | FL
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Zip | 33075-2001
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Country | US
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Telephone | 954-805-4480
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Fax | 954-805-4480
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Provider Business Mailing Address
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Address Line | 3255 NW 94TH AVE #8736
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City | CORAL SPRINGS
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State | FL
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Zip | 33075-2001
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Country | US
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Telephone | 954-805-4480
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Fax | 954-805-4480
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Authorized Official
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Title or Position | CEO
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Name | MR. DWAYNE COOMBS
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Credential |
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Telephone | 954-805-4480
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | C5Q7D6S2
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License Number State | FL
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